Form Sfn 5556 - Application For Insurance (Page 3 of 3) in pdf

APPLICATION FOR INSURANCE

PAGE 3 OF 3

Legal Name of Entity or Individual

NAME(S) OF OWNERS, PARTNERS, CORPORATE OFFICERS

Is Coverage

Name

Title

Address

Home Phone

Soc. Sec. No.

% Owned

Desired?

Yes

EMPLOYER(S) OPTIONAL COVERAGE: (additional sheets may be attached) Coverage for the owner, partner or corporate

officers of a business corporation is optional. Check coverage boxes above, if coverage is desired. An employer electing optional

coverage will be charged an annual premium based upon the maximum taxable payroll cap. An optional coverage contract will be sent

to you. Coverage becomes effective upon WSI's receipt of that completed, signed contract.

EMPLOYER'S SPOUSE AND/OR CHILDREN COVERAGE: You must list the spouse and all children under the age of 22 of the

employer(s) who have received or will receive compensation from your business. COVERAGE FOR SPOUSE AND CHILDREN

UNDER AGE 22 IS PROVIDED BY SPECIAL CONTRACT ONLY. Spouse - Premium calculated on wage cap amount. Children 21

and under for payroll period - Premium based on actual wages. Children 22 and older for payroll period - Actual wages would be

reported along with the other employees. Coverage becomes effective upon WSI's receipt of a completed, signed optional

coverage contract. (additional sheets may be attached)

Name of

Soc. Sec.

Date of

Relationship

Class

Actual

Estimated

Is Coverage

Family Member

No.

Birth

Code

Wages

Desired?

Yes

EMPLOYEE ACTIVITY AND ESTIMATED 12-MONTH PAYROLL (additional sheets may be attached)

Describe each unique type of work performed within the business (e.g., clerical office, janitorial, traveling personnel, etc.) List the

number of employees engaged in that type of work and estimate the payroll which will be expended for each in the next 12 months. If

you need assistance, contact Employer Services for more information at (701) 328-3800 or 1-800-777-5033.

Place Where Work Is Performed

Description of Work

Number of Employees (not

Estimated payroll (include

Performed

including owners)

room and board allowance)

EXTRATERRITORIAL COVERAGE

Do you anticipate having any North Dakota based employee(s) that will travel outside ND for work?

Yes

Do you intend to cover your ND based employee(s) under your WSI policy while temporarily working outside ND?

Yes

If yes, please indicate those state(s) in which your ND based employee(s) will be working.

If no, do you have separate coverage in the state(s) where the employee(s) will be working?

Yes

PENALTY FOR FILING FALSE PAYROLL WITH WORKFORCE SAFETY & INSURANCE

North Dakota law provides that any employer who willfully misrepresents to WSI the amount of payroll upon which compensation

premium is based is guilty of a Class A misdemeanor. If the premium owing exceeds $500, the employer is guilty of a Class C felony.

The employer is also civilly liable to WSI in the amount of THREE (3) times the difference between the premium paid and the amount

that should have been paid.

I acknowledge that I have read this Fraud Warning and understand that failing to secure workers' compensation coverage, filing a false

payroll report, or willfully misrepresenting the amount of payroll is a criminal offense. I understand that WSI is relying upon the truth of

my statements on this application. I CERTIFY THAT I HAVE NOT FILED ANY FALSE PAYROLL INFORMATION, NOR MADE ANY

FALSE STATEMENT, NOR KNOW OF ANY FALSE STATEMENT MADE IN CONNECTION WITH THIS APPLICATION.

I declare that the payroll information entered on this report is true, correct, and accurately reflects the identity of owners or officers, and

earnings of all covered employees. I have read and understand this Fraud Warning.

Signature of owner/officer

Printed Name

Date

Title

Phone

Form Sfn 5556 - Application For Insurance Page 3

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